Flesh insight from an esteemed St. Louis plastic surgeon

Leroy Young, a short, pot-bellied man with a tan, smooth complexion, sits at his cluttered desk on a recent afternoon and Googles "large labia."

"Look," he exclaims. "There are places that franchise it now, like McDonald's." He's talking about labiaplasty, a surgical procedure that eliminates excess skin from a woman's inner or outer vaginal lips.

Young, one of the nation's pre-eminent plastic surgeons, has just emerged from a post-operative exam with a 22-year-old patient and is eager to compare her result with some cyber-erotica. "Get this," he says, clicking on a link to "Designa Vagina Lips to Die For." The doctor chuckles as he reads an entry from a commenter who calls himself "Rich48.": "So you have big lips. Or small lips. Or maybe one is longer than the other. SO WHAT? From a purely cosmetic point of view, why would you risk a medical procedure to change it? Who will ever see it besides your GYN and your lover?"

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"Gotta give him credit," says Young, who, until a few years ago, tended to agree with Rich48's assessment.

Young had recently opened a private practice after 21 years in academic medicine, and he and his two partners fully expected to offer the standard bill of fare  tummy tucks, breast implants, liposuction, face lifts. But labiaplasties? Never. Then, one winter morning, he was leaving a consultation with a breast-augmentation patient when the woman said, casually, "Oh, doctor? By the way: My labia really bother me. Could you do anything about it?"

Young took a step back into the room and was quiet for a moment. "Let me see here," he finally said, hunkering down to take a look through his square, oversize glasses. The woman's inner labia extended a few centimeters beyond her outer lips. "I told her she seemed normal to me, but she wouldn't buy it," Young recalls. "She kept insisting: 'It bothers me with certain pants, and when I'm intimate, and I want [the extra skin] removed.'

"I thought it was crazy," the 60-year-old physician continues. "I thought it had something to do with pornography. Maybe, you know, her boyfriend had said: 'You don't look like the pictures in the magazines.'"

Young says he's never perused an issue of Playboy in his life, and when it comes to understanding what men might expect of their lovers, the doctor considers himself no authority. He married the first girl he ever kissed and, after they divorced, he wed his second-ever girlfriend.

"In my first year of medical school, we had to do a psychiatry rotation," Young recalls. "You had a whole questionnaire of stuff you had to go through with patients. Well, there I am on my first day, and I start off with this attractive woman. I'm going down my list, and I get to the question, 'Have you ever had kinky sex?' The woman kind of pauses, and says, 'What do you mean?' I said to her, 'I was hoping you would know.'"

And so, in the name of research, the doctor went trolling through cyberspace and was quickly reassured to find a range of labia sizes and shapes described as attractive. "I even found a tribe in Africa where the women stretch their lips, because they think it's beautiful," he remembers.

Young would soon discover that functional issues drive some of the growing demand for labiaplasties. "These women feel really stressed out when they first come in. They have issues related to their clothes, particularly swimsuits, or to hygiene," Young explains. In the end, he decided to go through with his first labiaplasty, and now performs several a month, at $3,000 per surgery.

The 22-year-old patient Young saw moments ago was a timid blonde who had her inner labia trimmed in the hospital. "I think it looks awesome," Young told her. When she didn't respond, the doctor held a mirror between her legs. She glanced down and smiled.

Back in his Creve Coeur office, Young closes the "Designa Vagina" page and calls up his favorite labia-related site. "Here we go  the-clitoris-dot-com. This one is really good." Young points the mouse over a wrinkly set of lips, dismissing them as "a head of cauliflower" before scrolling down the Web page to a pearly pair and pausing.

"A rosebud. It's pink; it's pretty. Yep, she could be in any magazine."

Leroy Young is a hopeless romantic. He composes love poems for his wife and dissolves into tears while watching Hoosiers. His prized possessions are his mother's petunias and the cane-bottom rocking chairs from the old family farm in Kentucky. He drinks Coors Light and sauerkraut juice and cleans his own toilets every Sunday. The doctor washes his hair with soap, gets his dress-down clothes straight off the racks at Wal-Mart.

"When I first knew him he wore blue socks with everything," says his wife, Jill.

"He would be the last person in the world to have plastic surgery himself," adds his daughter, Ann Elizabeth Mohart.

Young drives a used Ford Ranger. Before that, he drove a dented fifteen-year-old station wagon with missing hubcaps that he nicknamed "Vulva the Volvo."

"It brought a tear to my eye when they took her away last year, but I had to give her up because C.B. and Rob wouldn't go places with me," Young recounts, referring to his medical partners, C.B. Boswell and Rob Centeno, both of whom use Botox and exercise regularly, believing slender figures are a key selling point in luring clients. Young, on the other hand, loves nothing more between surgeries than a double order of sauerkraut and wieners.

Says Mohart: "If I had to sum up my dad in one phrase, it would be: 'You can take the boy out of the country, but you can't take the country out of the boy.'"

Young was born to Southern Baptist tobacco farmers in Oneida, Kentucky. The family was poor and isolated, living fifteen miles from the nearest traffic light. "I wish I could take you back there," he says. "Everybody had a mule."

An only child, Young passed the time hunting squirrels with his mutt, Soup, or pulling pranks with his BB gun. "One Saturday I shot the TV when Buffalo Junior and his Indian buddy were fighting bad guys," he recalls. Another day, "Granddad was standing between two buildings peeing, and I just couldn't pass it up. I shot him in the ass!"

On a lark, Young set off for medical school at the University of Kentucky, all the while believing he'd soon flunk out and hightail it back to the tobacco fields. Instead, he became so enraptured with anatomy and organic chemistry that he couldn't stay away from the campus. In his second year, he moved into the physicians' lounge of the teaching hospital.

"It was kind of like Vegas. It never closed," he recalls. "If I got bored studying, I'd go down to the ER. One of the doctors there taught me how to sew. He let me sew up drunks."

Seeing a breast augmentation early in his plastic-surgery rotation left quite an impression on Young. "I was wowed. In such a short time, you can have such an impact on somebody's body image, and your work is there for everyone to see. You can't hide any mistakes."

Though he hasn't acquired the stardom of Beverly Hills' Roberto Rey Jr. on the reality TV show Dr. 90210, Young is held in high regard among his peers. He recently became president of the Aesthetic Surgery and Research Foundation and is slated to take the helm of the American Society for Aesthetic Plastic Surgery in 2008.

His seventeen-page résumé cites an editorship at a prestigious medical journal and chairmanships of numerous national research committees, not to mention a dozen meritorious awards and advisory roles with the Food and Drug Administration. In fact, Young is now preparing to begin an FDA-funded study of lipodissolve  injections of enzymes purported to dissolve fat cells.

When thousands of women claimed their silicone-gel breast implants were causing sickness and cancer in the early 1990s, Young's research proved there was no correlation between silicone gel and autoimmune or connective-tissue diseases. It was his idea to establish the six-year-old North American Breast Implant Registry, an expansive tracking system of breast-augmentation patients.

Young publishes and lectures the world over. "Leroy will get up to give a talk and start by saying, 'Well, I don't know if I know what I'm talking about,'" observes Monte Eaves, a plastic surgeon from Charlotte, North Carolina. "But then he shows 800 slides. Not only does he know what he's talking about, he knows it better than everybody else."

Young came to St. Louis in 1977 for his residency at the invitation of Paul Weeks, his former instructor in Kentucky and then-chief of plastic surgery at Washington University School of Medicine and Barnes-Jewish Hospital.

As the first United States medical center to open a reconstructive surgery department in the 1940s, Wash. U./Barnes has enjoyed a storied reputation in the field. Young became a professor at the university in 1979, treating burn victims, congenital deformities and people disfigured by disease. Ten years later Young convinced Weeks to add an aesthetic-surgery component.

"I was really getting interested in breasts and genitalia," says Young, who has performed sex-change surgeries on hermaphroditic children and transsexuals. "I initially thought it was morally wrong to change somebody's gender. I thought, 'Gee, you know, you're tinkering with what God's done.' But then I'd talk to these people  they felt trapped, imprisoned  and I thought a compassionate God wouldn't want anybody to feel that way.

"One Friday we cut off this guy's genitals and made him a vagina, and I went up Saturday morning to make rounds and there was a sign on his door saying, 'It's a girl!'"

Young consulted patients during a two-year period of cross-dressing before performing any surgeries. "Sometimes I'd get confused," he recalls, on the verge of laughter.

"But the funniest was this guy who was pretty skinny and not very pretty as a woman. I start telling him the first surgical step was breast implants, and he stops me right there. He says: 'Doc, you know I don't have much money.' He says: 'I know lots of women with small breasts, but I don't know any that got a dick, so I want to start there.'

"I stopped for a minute and thought, 'You know, there's no way I can argue with what he said.' So we made an exception in his case."

The work led Young to patent a penile implant. He and a fellow surgeon grafted a part of the urethra into an arm-skin flap  effectively growing a penis from an arm. It was the first device allowing men to stand while urinating and have an erection. Its nickname? "El Guapo."

Young, whose favorite actress is Lady Chablis, the transvestite in Midnight in the Gardenof Good and Evil, quit doing the costly sex-change surgeries in the 1990s. But every so often he's reminded of his work. While waiting in line last year at a Chinese buffet in Belleville, he felt a tap on the shoulder. He turned around, only to find one of his old transsexual patients about to sit down to dinner  with his wife and children.

Some of the first Americans to experiment with cosmetic surgery were syphilis sufferers with depressed noses, according to Venus Envy: A History of Cosmetic Surgery by Elizabeth Haiken. It was the late nineteenth century, and the handful of doctors willing to treat these patients tried everything, from bone grafts to injections of paraffin mixed with Vaseline, white-oak bark or goose grease.

Beginning in the twentieth century, demand for facial surgeries rippled through a cross-section of society, including actresses, socialites  even outlaws on the lam. In 1924 the New York Daily Mirror awarded "the homeliest girl in New York" a surgical makeover. Seven years later a doctor reportedly performed the first public facelift in a New York City ballroom before hundreds of spectators.

For most of the twentieth century, though, the medical profession dismissed cosmetic surgery as a morally repugnant, risk-laden back-room venture  or, as Haiken writes, "the province of charlatans and quacks."

Only in the past decade has the specialty acquired true mainstream acceptance. According to the American Society for Aesthetic Plastic Surgery, doctors have more than quadrupled their aesthetic procedures since 1997. Last year alone, more than 8 million Americans opted for minimally invasive treatments, such as Botox, and more than 2 million people chose cosmetic surgeries  with liposuction being by far the most popular.

The latter statistic doesn't include penis-widening, scrotal lifts or hymenoplasties (the tightening of a woman's hymen, colloquially known as "revirginizing")  even though patients across the nation are beginning to request these operations.

Vanity, plain and simple, is the number-one motivator.

"Thirty years ago my colleagues in the mental-health profession believed anyone who changed their appearance was dealing with pretty significant psychological problems," observes David Sarwer, a psychologist who presides over the Center for Human Appearance at the University of Pennsylvania.

"More recent research suggests there are very few differences today between those who seek cosmetic surgery and those who don't," Sarwer continues. "Having surgery is not about repairing long-standing conflicts with parents or curing a failing romantic relationship."

Says Guy Stofman, chief of plastic surgery at Mercy Hospital of Pittsburgh: "People want it, they can afford it, and they do it. It's no different than buying a luxury car."

Plastic surgeons are often referred to as "psycho-surgeons," since they must interview patients carefully to weed out the "wackadoos," as Leroy Young calls them.

"Right after my residency ended, I'm seeing patients one day and in comes this guy who says he got sent by the CIA," Young recounts. "He tells me he has to go on a little covert mission, and they want him to get a facelift." Young made a call to the agency at the man's insistence, only to learn he was well known to the CIA "as a total nut."

Some patients appear perfectly normal initially, Young adds, only to pull out a magnifying glass to prove even their slightest defects.

"I saw a 37-year-old woman recently who's already had upper and lower brow lifts, five rhinoplasties [nose jobs], eight or nine breast jobs; and four or five rounds of liposuction," notes Young's partner, C.B. Boswell. Most recently, the woman wanted a facelift.

"So I looked at her, and I said, 'Um, what bothers you, exactly?' She said: 'My jowls are loose.' But you look at her, and she's perfect. This lady has no anatomical thing I could correct."

The male equivalent is known in the profession as a "SIMON"  a single, immature, male, over-expectant narcissist. "People who meet those criteria aren't going to be happy with anything," says Boswell. "You probably don't take them on."

As Young sums up: "Frankenstein's rule: The person that makes the monster keeps the monster."

Doctors are still unsure as to what causes silicone-gel implants to fail, but sometimes they do. Early one morning last month, Young is removing a ruptured device from a svelte 63-year-old. Clear goo oozes through his knobby fingers as he arcs his right arm dramatically above the breast.

"Remember Ghostbusters!" he yells. "Slimer!"

Young proceeds to tell the staff the woman had the implants for 28 years but is suing the manufacturer, Dow-Corning. "Tasted the nectar and didn't like it," cracks Rob Centeno.

"You know that song, 'The good things in life are free, but what I need is money,'" replies Young, as he begins burning a white ring of brittle calcium inside the woman's breast.

"Silicone is extremely inert," says Centeno. "It's so safe they use it in Pam cooking spray."

"FDA-approved for baby formula, too," Young adds. "What's dangerous is what happened to a patient who came in about a month ago."

The St. Louis woman, says Young, went to a local hotel room, where she plumped up her breasts with injections of industrial-grade liquid silicone. "Supposedly there's a woman who comes down from Chicago and does it," Young says. "The patient got worried because she had a mammogram, and it looked like a bag of grapes in there."

Young and the staff agree that they'd approve of breast augmentations for their own daughters as long as they knew the risks: hardening, deflation and altered sensation.

"And there's always the risk men won't look you in the eye," adds Young. "One time we were operating  it was a breast reduction  and we had this new anesthetist. The conversation got onto how socially awkward it is to have big breasts. Well, I looked at the new nurse, and I said, 'You know, I can understand  it's the same thing for guys with big dicks!'"

With his Kentucky twang and folksy manner, Young manages to get away with some risqué remarks other surgeons wouldn't dare utter. "Is she recently single?" he asks one day, noticing the shaved pubic area of a young patient asleep on the OR table. On another occasion, he enters a post-op exam and says to a breast-augmentation patient, "You're going to do some damage at the pool this summer, aren't you?"

"It's better than that little gal we put implants into last week," says a nurse.

"Oh yeah, she had nothing," says Young. "When I interviewed her, I said, 'Now what is your goal?' She looked at me like I had three heads. She said, 'Doctor, I want big breasts!'"

Young, Centeno and Boswell are known as "Da Boys" to the OR staff at Barnes-Jewish West County Hospital. Each has a specialty: Young, the breasts and genitalia; Centeno, the nose and body contouring; Boswell, the face. They operate as a team  unusual in the field  often with the Bavarian State Orchestra or Guns N' Roses streaming from their iPods.

The doctor's next patient this March morning is a fortysomething blond with skin the color of caramel and size-D implants. "Those are some biiiiiiig breasts," he says, donning latex gloves. "We're going to put some smaller implants in. Sometimes life involves a trade."

The nurses haven't yet arranged all the tools Young needs, so he surveys the room, gloved hands resting on his belly. The doctor rarely chides anyone, but it's easy to spot annoyance in his silence. He hates wasting time, especially with "OAFAT": Obligatory Anesthesia Fuck-Around Time, as one OR nurse calls it.

A minute after making the first incision, Young removes an implant and hands it to a nurse. Another assistant drops the capsule into a white plastic container for him to cart home.

"We've got two or three thousand implants in [an assistant's] basement, in case we want to study them," he says. "I used to save gallstones, too, but that was a long time ago. You could make necklaces out of them  kind of a Native American look."

Young positions his scissors at the bottom of the right breast and begins stitching a suture: a small pedestal for the implant to rest on and prevent the nipple from turning upward.

A few minutes later his face reddens as he uses his whole body to press the woman's new implant through the small incision above her nipple.

"Like trying to put a cantaloupe through a straw," he mutters. "There we go, that's a nice little titty."

After a brief lunch  sauerkraut and wieners  it's on to liposuction for two women, both pale and rotund. Young pokes a cannula through a small incision and probes over a five- or six-inch area  a violent motion that resembles sawing. Chunks of yellow fat come slogging through a clear tube attached to a gray apparatus that looks like a vacuum. The fat then collects in clear, 1,000-gram canisters. Blood settles at the bottom.

Sometimes Young or one of his partners will spin the fat in a centrifuge and inject it into the patient's lips  about a three-minute procedure. "It only lasts six or eight months, because think about how much your lips move all the time," says C.B. Boswell. "But we can do it in the office  just suck a little a fat off a person's knee near their thigh and inject that. It's normally $1,500 to $2,000."

Adds Young: "You want to leave a little padding  about one centimeter  between the skin and the muscle. Remember 'The Princess and the Pea'?"

The only decoration adorning Rob Centeno's office is a girly calendar opened to a blond bombshell with a honey-colored derriere. "Leroy gave that to me as inspiration for my research," he explains. "The Greeks would call her kallipygos. We'd say callipygian, or bootylicious. Did you know 'bootylicious' is even in the dictionary?"

Centeno is among a handful of doctors nationwide mastering gluteal aesthetics. Two years ago, he recruited subjects through local gyms and bikini contests, and studied almost 200 photos from celebrity and X-rated Web sites, trying to formulate the proportions of a perfect posterior.

"It's gotten gradually larger through the years," he says. "Think of Twiggy in the '70s, Kate Moss in the '80s  then Claudia Schiffer in the '90s." And today? "Definitely Britney Spears  before she got pregnant."

Centeno traveled to Mexico City to watch surgeons there perform gluteal augmentations. He then practiced on cadavers locally to put his own newfangled set of complex ratios into practice. He uses solid silicone implants or fatty tissue from the patient's own body to plump up the rear end.

More than 2,300 Americans had gluteal augmentations last year, according to the American Society for Aesthetic Plastic Surgery. In St. Louis, says Centeno, it's not unusual to greet patients bringing in magazine photos of Jennifer Lopez or Beyoncé and asking, "Can I have this ass?"

What got Centeno interested in gluteal aesthetics was operating on the morbidly obese. "People lose all this weight, but they end up with no butt," he explains. "Well, we decided we could recycle tissue from other areas of their body to restore the volume."

Massive-weight-loss patients typically have nutrient deficiencies and other health problems that make them riskier candidates for cosmetic surgery. Still, they are the fastest-growing patient population in the field, thanks to the surge in gastric-bypass operations during the past five years.

"Many of us think there won't be enough plastic surgeons to serve all these patients ten years from now," says Young. "It took the whole specialty completely by surprise."

After shedding hundreds of pounds, massive-weight-loss patients typically end up saddled with extra skin that refuses to contract. "We had one patient who liked to ride a motorcycle, but her arm skin would flap in the wind," says Young. "I had one who was a cook, and when she'd go to the grill her arm skin would graze it and get burned," adds Centeno.

"I thought I looked like a melted candle, or a mudslide," says Amy French, a 35-year-old from St. Peters who lost 159 pounds after a gastric bypass. "If you took a golf ball and put it in a tube sock, that's what my breasts looked like."

The hallway outside the plastic surgery unit at Barnes-Jewish West County Hospital reeks of meat singeing on a griddle when massive-weight-loss patients recline on an OR table. Almost all of them require liposuction, but first the doctors have to spend hours burning through the extra skin and tissue to extract the fat.

"We get lost in here," says Centeno.

"Yeah, it's weird," Boswell adds. "Their muscles end where yours and mine do. There's almost always a really small person inside the large one."

The biggest trouble spot is the pannus, a flap of extra skin resembling an apron that hangs down from the stomach and lower back  sometimes as far as the knees.

"It'll hang so low they can't perform hygiene," says Young. "They get yeast infections. They can't wipe their bottom. One woman told us the only way she and her husband could have intercourse was when one of the neighbors came over and held the pannus up!"

Young and his partners have removed more than 70 pounds of extra stomach and back skin in a single body-lift surgery  far too much for the little gray Sunbeam kitchen scales in the ORs at Barnes West. But the nurses cut the flesh into pieces the size of salmon steaks and weigh them so the doctors can give final tallies to the paying customers.

Thirty-nine-year-old Cathy Haug of Bridgeton lost 200 pounds after a gastric bypass. Young gave her a body lift and gluteal augmentation in December. "I got out of bed and thought I was going to die," she says. "My body was traumatized."

Haug had to sleep in a recliner and couldn't stand straight for two weeks. Drains protruding from her torso exuded fluid "like murky water" well into January. The following month she had to pad her underwear with cloth diapers because her wounds separated and started leaking black goo.

Haug nonetheless drops her pants to show her taut tummy and scars to a new acquaintance in a parking lot. "I want Dr. Young to do my arms next," she says. "I can't wait."

Three years ago Leroy and Jill Young left Clayton for a rustic three-acre spread in Wildwood. Their Dobermans have the run of the place, with their doggie portraits occupying the living room.

Young keeps in his second-story office a black marble statue of Nefertiti, queen of Egypt  "one of the definitions of classic beauty," he says. Two shelves above lies an old SS Nazi helmet that the doctor bought over the Internet. "I've always been fascinated by the SS," he explains. "They were very good at what they did  so well-trained  even though they were evil."

The home's crowning jewel is the land surrounding it. "It was a compromise," he says. "I wanted a lot more. I wanted a lake or a pond." It's no Kentucky farm, but there's ample room for Young to grow his leeks, onions, lettuce and raspberries.

After checking on a pot of red beans and rice and taking a seat on the edge of a leather chair, Young reflects on the most difficult cases of his near-30-year career. There was the little lady whom he had to scalp to get rid of a disfiguring cancer. The older woman with exposed brain who would have suffered a stroke had he made the wrong split-second decision. The lung-cancer victim he treated and gets a Christmas card from each year.

"Did I tell you about the little lady and man who couldn't have intercourse?" he abruptly asks.

The Iowa couple came to Young over a year ago. The wife's vulva, remembers Young, was shrunken and tightened after radiation for cancer.

Young performed a skin graft to the vulva, which seemed to do the trick for a while. But several months later the woman's cancer reappeared, and again, she was out of sexual commission. The couple came back to Creve Coeur, desperate.

"Even though they were in their sixties, sex was really important to this couple," Young recounts. "They were like a little pair from a Winslow Homer painting, or straight out of a Rockwell. We tried everything to get them going  surgeries, medicines. And nothing worked. I was just about ready to tell them we were at the end of the rope, and I was trying to figure out how to do it, when she says: 'Listen, doctor, isn't there anything else you can do?'

"Into my head popped the drug DSMO. It increases blood flow. It's a topical drug, and I had a bit of it on my desk, and I saw it.

"Two months later they came back all smiles. I said: 'How'd it go?' They said: 'We're able to have full penetration.' They gave me a huge hug and went on their way."